Infratrochlear neuralgia: A prospective series of seven patients treated with infratrochlear nerve blocks.

Background Infratrochlear neuralgia is a recently described painful cranial neuropathy that causes pain in the internal angle of the orbit and the medial upper eyelid, the upper bridge of the nose and/or the lacrimal caruncle. We aim to present seven new cases of infratrochlear neuralgia treated with anaesthetic nerve blocks. Methods Over an 18-month period, we prospectively identified seven cases of infratrochlear neuralgia among the patients attending the Headache Unit in a tertiary hospital. Anaesthetic blocks were performed by injecting 0.5 cc of bupivacaine 0.5% at the emergence of the nerve above the internal canthus. Results All patients were women, and the mean age was 49.1 years (standard deviation, 17.9). The pain appeared at the internal angle of the orbit and/or the medial upper eyelid in six cases, and the whole territory of the infratrochlear nerve in one case. Six patients had continuous pain and one had episodes lasting 8-24 hours. All patients showed sensory disturbances within the painful area and tenderness upon palpation of the infratrochlear nerve. Nerve blocks resulted in complete and long-lasting relief in four patients and short-lasting relief in the other three patients. Conclusions Infratrochlear neuralgia should be considered among the neuralgic causes of orbital and periorbital pain. Anaesthetic blocks may assist clinicians in the diagnosis and may also be an effective therapy.

Supratrochlear Neuralgia: A Prospective Case Series of 15 Patients.

OBJECTIVE: The aim of this study was to describe clinical features unique to supratrochlear neuralgia. BACKGROUND: The supratrochlear nerve supplies the medial aspect of the forehead. Due to the intricate relationship between supraorbital and supratrochlear nerves, neuralgic pain in this region has been traditionally attributed to supraorbital neuralgia. No cases of supratrochlear neuralgia have been reported so far. METHODS: From 2009 through 2016, we prospectively recruited patients with pain confined to the territory of the supratrochlear nerve. RESULTS: Fifteen patients (13 women, 2 men; mean age 51.4 years, standard deviation 14.9) presented with pain in the lower paramedian forehead, extending to the eyebrow in two patients and to the internal angle of the orbit in another. Pain was unilateral in 11 patients (six on the right, five on the left), and bilateral in four. Six patients had continuous pain and nine described intermittent pain. Palpation of the supratrochlear nerve at the medial third of the supraorbital rim resulted in hypersensitivity in all cases. All but one patient exhibited sensory disturbances within the painful area. Fourteen patients underwent anesthetic blockades of the supratrochlear nerve, with immediate relief in all cases and long-term remission in three. Six of them had received unsuccessful anesthetic blocks of the supraorbital nerve. Five patients were treated successfully with oral drugs and one patient was treated with radiofrequency. CONCLUSIONS: Supratrochlear neuralgia is an uncommon disorder causing pain in the medial region of the forehead. It may be differentiated from supraorbital neuralgia and other similar headaches and neuralgias based on the topography of the pain and the response to anesthetic blockade.

Topographic Relationship between the Supratrochlear Nerve and Corrugator Supercilii Muscle--Can This Anatomical Knowledge Improve the Response to Botulinum Toxin Injections in Chronic Migraine?

Chronic migraine has been related to the entrapment of the supratrochlear nerve within the corrugator supercilii muscle. Recently, research has shown that people who have undergone botulinum neurotoxin A injection in frontal regions reported disappearance or alleviation of their migraines. There have been numerous anatomical studies conducted on Caucasians revealing possible anatomical problems leading to migraine; on the other hand, relatively few anatomical studies have been conducted on Asians. Thus, the aim of the present study was to determine the topographic relationship between the supratrochlear nerve and corrugator supercilii muscle in the forehead that may be the cause of migraine. Fifty-eight hemifaces from Korean and Thai cadavers were used for this study. The supratrochlear nerve entered the corrugator supercilii muscle in every case. Type I, in which the supratrochlear nerve emerged separately from the supraorbital nerve at the medial one-third portion of the orbit, was observed in 69% (40/58) of cases. Type II, in which the supratrochlear nerve emerged from the orbit at the same location as the supraorbital nerve, was observed in 31% (18/58) of cases.

[Myokymia of the obliquus superior muscle and cryptogenetic epilepsy]. / Myokymie des Musculus obliquus superior und kryptogene Epilepsie.

BACKGROUND: Myokymia of the obliquus superior muscle is a rare episodic microtremor caused by uncontrolled activities of the trochlearis nerve fibres. Epilepsy is also caused by spontaneous discharges of neurons. In our report we present an associated epilepsy which to the best of our knowledge is described for the first time. PATIENT: An 61-year old man with twitches of the right eye for 6 weeks and a subjective feeling of eye movement was investigated at our hospital. His history was void of any ophthalmologic diseases. However, he suffered from cryptogenetic epilepsy known since childhood. The morphological and orthoptical findings of his eyes were normal. During the slit-lamp investigation a unilateral rotating microtremor of the right eye induced by looking downward was seen. The neurologic investigation, magnetic resonance imaging and assessment of the thyreoid function did not show further pathological results. The patient underwent treatment with carbamazepine. Under this therapy he did not show any symptoms of myokymia during follow-up. SUMMARY: To the best of our knowledge this is the first case of myokymia of the obliquus superior muscle associated to epilepsy. To our opinion, any case of this syndrome should be investigated for epilepsy. A causal relation is unlikely since the most probable etiologies are either spontaneous discharges of trochlear nucleus neurons or a close contact between vessel and nerve analogously to trigeminal neuralgia.

Methyl iodide poisoning: report of two cases.

Two workers were poisoned following exposure to methyl iodide with inadequate protective devices. Their cases are presented together with a review of literature. Both patients developed symptoms and signs of cerebellar lesions and damage of the third, fourth, or sixth cranial nerve pathways. Spinal cord lesions producing motor and sensory disturbances were present in one. Late psychiatric disorders were observed in both patients. Although these symptoms were very similar to those reported in the nine published cases of methyl iodide poisoning, the toxicological diagnosis was delayed in one case: as repeated overexposure produced recurrent attacks of multifocal neurological dysfunction, multiple sclerosis was initially diagnosed, although several of the features observed are unusual in this disease. The manifestations of methyl iodide poisoning are similar to those of intoxication with other monohalomethanes. All these compounds probably share the same mechanisms of action. This mechanism and its therapeutic consequences are discussed.

The effect of bupivacaine skull block on the hemodynamic response to craniotomy.

The placement of pointed cranial pins into the periosteum is a recognized acute noxious stimulation during intracranial surgery which can result in sudden increases in blood pressure and heart rate, causing increases in intracranial pressure. A skull block (blockade of the nerves that innervate the scalp, including the greater and lesser occipital nerves, the supraorbital and supratrochlear nerves, the auriculotemporal nerves, and the greater auricular nerves) may be effective in reducing hypertension and tachycardia. Twenty-one patients were allocated in a prospective, double-blind fashion to a control group or a bupivacaine group. After a standardized induction and 5 min prior to head pinning, a skull block was performed. Patients in the control group received a skull block of normal saline, while the bupivacaine group received a skull block with 0.5% bupivacaine. Systolic (SAP), diastolic (DAP), mean arterial pressure (MAP), heart rate (HR), and end-tidal isoflurane were recorded at the following times: 5 min after the induction of anesthesia, during performance of the skull block, during head pinning, and 5 min after head pinning. Significant increases in SAP of 40 +/- 6 mm Hg, DAP of 30 +/- 5 mm Hg, MAP of 32 +/- 6 mm Hg, and HR of 22 +/- 5 bpm occurred during head pinning in the control group, while remaining unchanged in the bupivacaine group. These results demonstrate that a skull block using 0.5% bupivacaine successfully blunts the hemodynamic response to head pinning.

Innervation and anesthesia of the antler pedicle in wapiti and fallow deer.

The heads from 6 mature male wapiti and 8 mature male fallow deer were dissected to provide a description of the nerves supplying the antler pedicles. Innervation in both species was found to resemble that of the red deer, with major contributions coming from the infratrochlear and zygomaticotemporal nerves. All heads displayed a dorsal branch from the auriculopalpebral nerve, but in only 2 wapiti and 3 fallow deer heads was this branch observed travelling to the pedicle. The dorsal branches of the 2nd cervical nerve were isolated in each head but could not be traced to the pedicles. Failure to induce anesthesia of the antler employing specific nerve blocks on the infratrochlear and zygomaticotemporal nerves can occur if the dorsal branch of the auriculopalpebral nerve is not blocked.

Temporary paralysis of cranial nerves III, IV, and VI after a Gow-Gates injection.

A case of temporary complete paralysis of cranial nerves III, IV, and VI, after a Gow-Gates injection is reported. The proposed explanations for the mechanisms of occurrence are described. Although the Gow-Gates technique has many advantages, it is not without complications. To avoid such complications, it is important to take the following precautions when using the Gow-Gates technique: because of the proximity of the internal maxillary artery (accessory and middle meningeal) and the pterygoid plexus of veins, and because the anesthetic is injected quickly, it is paramount that careful aspiration be performed before administration of the local anesthesia; injections should be on or within 1 mm to 2 mm of the condylar neck.

Oculomotor palsy following dental anesthesia.

Paralysis of the right third and fourth cranial nerves, lasting for about six weeks, occurred in a patient following the injection of procaine hydrochloride in the area of the right superior alveolar artery. Ocular complications of dental anesthesia are rare and are probably caused by intra-arterial injection of anesthetic that reaches the orbit via an anastomosis between the middle meningeal and ophthalmic arteries. Such complications include transient oculomotor palsies and permanent or transient loss of vision.

Functional changes in the oculomotor system of the monkey at various stages of barbiturate anesthesia and alertness.

1. Single units in the III. and VI. nerve nuclei were continuously recorded together with vestibular stimuli and eye movements in macaques before, during, and after administration of barbiturate. 2. The visual input was functionally detached from the oculomotor system during the deeper stages of anesthesia, whereas some kind of vestibulo-ocular response could always be elicited. 3. The finding of various phase values between the maximum impulse rate IRmax of oculomotor units and the maximum stimulus velocity vmax during 1 Hz sinusoidal vestibular stimulation ranging from about 65 deg phase lead to 65 deg phase lag is suggested as important for the explanation of the phase shifts between head rotation and eye movement during anesthesia. 4. The phase relationship between IRmax and vmax was found to be unchanged, whereas the characteristic of IRmax versus vmax was highly sensitive to arousal stimuli for some oculomotor neurons. This sensitivity was represented exclusively by activation rather than inhibition.